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Category Archives: Medical Directives

Question: I’m a recent graduate from the paramedic program and was wondering if I can get some feedback regarding the hypoglycemia treatment. The new protocol that came into play that now includes D10, I was curious what the reasoning was for choosing D10 over D50? Is there anything specific separating the 2 options of treatment?

Answer: This is a very good question. Traditionally, the standard dose of 50 mls of D50 (25 grams of dextrose in 50 ml of water) was used to treat hypoglycemia in adults. As of 2015, most American EMS Services used this preparation (1). Anecdotally, this has worked well and there were no concerns about providing too much glucose. Recently concerns have been raised that the dose is far above what is needed to treat most cases of hypoglycemia. In addition, the potential neurotoxicity of hyperglycemia especially in children, and the accidental tissue necrosis from extravasation of a large amount of hypertonic D50 into soft tissues have started Services to use less concentrated dextrose (D10) solutions to treat hypoglycemia (2).

Question: Case - Adult patient experiencing an asthma attack. Wheezing in all fields (air entry in all fields) and tachypnea. Historically, we've been taught to administer Epi in cases of 'silent chest', absent air entry in any fields or patient requiring BVM ventilation. The BVM ventilation has always been associated with diminished air entry/silent chest, but not really with hyperventilation. The old BLS stated to assist with BVM ventilation in any patient with a RR>28. Does this mean that if the patient has RR>28, therefore requiring BVM ventilation, he/she SHOULD receive Epi even if there is air entry (albeit wheezing) in all fields?

Answer: The Patient Care Standard does not answer your question. The Companion Document gives some guidance. On page 12 it states “Epinephrine 1:1,000 IM is indicated when the patient is asthmatic and BVM ventilation is required. This is typically after salbutamol has had no effect, however salbutamol could be bypassed and epinephrine be administered immediately due to the severity of the patient’s condition. The indications to administer epinephrine do not change based on the ability to administer salbutamol.” This is to be interpreted as meaning if the patient who is having an exacerbation of asthma and requires BVM support, then Epinephrine should be given if the other conditions are met.

Question: With the recent training surrounding hemorrhage control will we potentially see TXA administration added to our medical directives? Also wondering if you see pelvic binding brought into our skill set in the future?

Answer: There has been some discussion at the provincial MAC about the addition of Tranexamic Acid (TXA) to the ALS PCS to be used to control massive hemorrhage and continues to be considered as more evidence is generated. There is debate about its indications, how often it would be used in the Ontario setting, various protocols for its use, and concerns over its cost. The Crash-2 study, the largest study to support the use of TXA, in civilian settings, was based on administration of the drug in the Emergency Department (1). It demonstrated that TXA reduces mortality by about 10% measured at four weeks in hospital, with most of the effect achieved if you get the drug within three hours of being injured. So trying to show a 10% mortality benefit in 20 minutes of urban EMS contact time becomes a theoretical 1% benefit, and that is without all of the extra treatment challenges in an already very busy prehospital case, where we are also advocating not to stay on scene to start an IV. The Crash-2 study required twenty thousand cases to show an effect, and most trauma occurs in urban centres with fast transport times. There could be more theoretical value with long transport times or more geographically isolated situations, which is why most modern militaries are utilizing it in the prehospital environment for combat injuries, however there are not many cases worldwide, and treatment details are not standardized for studying.
There may be parts of Ontario where this could be theoretically beneficial and TXA utilized, and unlikely that there will be a large enough trial to show benefit. A smaller, more recent, cohort study of prehospital administered TXA did not show any overall mortality benefit (2). Crash-3 is currently looking at benefits with TXA in traumatic brain injury, and perhaps this will show an effect for prehospital care in the future.
You raised a concern regarding pelvic binding not being within the paramedic scope of practice, however it currently does exist.

Pelvic binding to control bleeding in pelvic fractures has some theoretical appeal, and it is certainly not a packaging device but a treatment device (3). The evidence for its effectiveness is mostly anecdotal. There are many challenges in applying this in the prehospital setting. Pelvic fractures are not as readily evident as external hemorrhage. None of the devices have been validated for prehospital situations, and are really based on cadaveric testing, with next to skin land marking, as we do in ER with patient fully exposed.

Question: I was looking through Ask MAC and there are a few questions pertaining to cardiac arrest and shocks or no shocks of other responders. Are Paramedics are to include shocks delivered by the Fire Department prior to arrival in their treatment of a VSA patient?

My understanding from teachings in 2014/2015 is that if Fire delivered shocks we could count what they did. If they did not, we did not count their no shocks and conducted our own working towards the medical TOR which is also covered in the Summary of Changes document.

The question on ASK MAC seems to say if we trust the responders we can count everything I was hoping for a clarification that can be searched when the question comes up again.

Answer: Thank you for raising the important and sometimes confusing issue. Also thank you for looking through ASKMAC for what answers had already been provided.

In summary: If a first responder does not deliver any defibrillations, the paramedics are to complete their medical cardiac arrest directive in its entirety. If a first responder has delivered a defibrillation, the paramedics count the number of analysis/defibrillations completed as part of the medical directive and continue within the medical directive from that point.

To elaborate: This information was covered during the 2016-2017 Mandatory CME, but a refresher is a great idea. As stated in the Companion Document, as a general rule, Paramedics do NOT count pre-arrival interventions into their patient care. Care delivered prior to arrival can be “considered” and documented. However, in the setting of cardiac arrest where a medical termination of resuscitation (TOR) might apply, the Paramedics will complete three (3) rhythm interpretations/analyses themselves rather than “count” the number completed prior to their arrival.

A “first responder” is defined as any responder to a victim of out of hospital cardiac arrest who arrives ahead of paramedics and performs CPR and rhythm analyses using an AED in an organized and appropriate AHA-HSFO Guideline compliant fashion such that, upon arrival of paramedics, the paramedic is readily able to determine the number of analyses completed and the current sequence to follow.

SWORBHP Medical Council believes that ANY defibrillation delivered to a patient during a cardiac arrest resuscitation should be “counted” and “considered” as a contraindication to the application of the TOR.

If a defibrillation has been delivered to a patient by first responders, the TOR rule would not be considered. Any analyses (NSI and “shock delivered” analyses) may be “counted” or “considered” into the total number of analyses performed by paramedics upon their arrival and transport initiated/patch performed as per the Advanced Life Support Patient Care Standards Medical Cardiac Arrest Medical Directive. In essence, the care provided by the first responder should be considered as part of the number of analysis/defibrillation allowed within the cardiac arrest medical directive.

If no defibrillations/shocks were delivered ahead of paramedic arrival, paramedics must continue to obtain 3 additional analyses themselves resulting in No defibrillation/No Shock Advised (NSI) prior to patching to the BHP for consideration of Termination of Resuscitation (TOR)/pronouncement regardless of the number of NSI analyses obtained by first responders. Hence, the care provided by the first responder should not be considered as part of the number of analysis/defibrillation allowed within the cardiac arrest medical directive.

Question: The Opioid Medical Directive allows for Naloxone to be administered 0.8mg SC/IM/IN and 0.4mg IV. The IV route allows the paramedic to titrate to restore the patient's respiratory status. Can this titration also be applied to the SC/IM/IN?

Answer: The dosing and intervals in the ALS PCS Opioid Toxicity Medical Directive for SC/IM and IN Naloxone are based on the pharmacologic properties of the drug and the route it is being given. Given the quick onset of action via the IV route, this property allows for titration of the dose to effect. SC/IM/IN routes have longer times to peak effect and therefore cannot be titrated, in addition to the actual mechanical difficulties of providing a titrated dose through these routes. Providing smaller doses via the SC/IM/IN routes that may be ineffective will lead to prolonged periods of hypoventilation given they cannot be ventilated with a BVM. The balance of prolonged periods of hypoventilation must be weighed against the risk of a large dose that causes acute withdrawal. Paramedics can give a maximum of 3 doses of SC/IM/ IN Naloxone which allows for titration to the clinical response.

Question: A couple questions with regards to D10. We have used D10 a few times now to treat hypoglycemia and have noticed some issues. It seems that for anyone with a BLG that is very low (say less than 2.0 for argument sake) the max dose of 10g will not get them over 4.0 mmol/L. Is there plans in the future to increase the dose? Perhaps something like if the patient is < 2.0 mmol/L then a 20g max or 4ml/kg loading dose followed by a 10g or 2ml/kg maintenance dose if necessary?

Second, with regards to Buretrol administration of D10, the process is very slow. Both the setup of the Buretrol and the infusion take quite a bit of time obviously more so if a second dose is required. Is there any reason a 60ml syringe can't be used (draw up and push 60cc and follow up with 40cc) as a push administration instead of the Buretrol? For most situations the slow drip is okay but in the case of an agitated or aggressive patient the quicker option would be nice. I realize the benefits of D10 over D50 in not sky rocketing BGL but the way it is laid out now seems that we have gone too far the other way in not raising BGL enough.

Answer: Thank you for the question. In regards to increasing the max dose of D10 based on the patient’s blood glucose level we will discuss this potential issue at the OBHG MAC during the next review of the medical directives.

In regards to pushing IV D10 – Pushing D10 via syringe is an acceptable practice. The Buretrol acts as a safety device to prevent larger volumes of fluids being inadvertently infused into children. Using a syringe to push D10 is the same mechanics as a Buretrol, only can be given quicker which is of no concern.

Question: My question is in regards to the moderate to severe allergic reaction and medical cardiac arrest. With the new changes, the moderate to severe allergic reaction directive allows us to administer 2 doses of epinephrine q 5 minutes to a max of 2. If a patient were to go into cardiac arrest due to anaphylaxis (after already administering 2 doses of epinephrine), are we still able to administer another dose under the medical cardiac arrest directive? (Leading to a total of 3 doses).

Answer: Great question. Previous administration of epinephrine is not an exclusion from epinephrine in the cardiac arrest medical directive. Therefore in the scenario described a paramedic could administer IM epinephrine to the anaphylactic patient who arrests. Given the failure of the 1st two doses of epinephrine to relieve anaphylaxis, focus should be on high quality CPR and rapid transport. Do not delay these two key components of care in order to give the third dose of epinephrine.

Question: Although very rare, how should Paramedics manage a uterine inversion?

Answer: Uterine inversion is very rare, but can be life-threatening. The majority of uterine inversion will not be apparent from external assessment and thus may be difficult to diagnose in the prehospital setting. As you know paramedics are not authorized to manually replace an inverted uterus. If a midwife is present they will do so by grasping the inverted uterus with a sterile gloved hand by “last out, first in” technique – pushing the uterus back inside and through the cervix. In the absence of a midwife on scene the paramedic would need to receive medical direction from the on-call base hospital physician.

Careful delivery of the placenta (gentle controlled cord traction during patient pushing/contraction) will dramatically limit the risk of uterine inversion

Question: Can we draw up D10 in a 50cc syringe and administer it that way instead of going through the Buretrol?

Answer: Pushing D10 via syringe is an acceptable practice. The Buretrol acts as a safety device to prevent larger volumes of fluids being inadvertently infused into children. It can also be utilized to deliver a specific volume of fluid (in this case D10). Using a syringe to push D10 is the same mechanics as a Buretrol, only can be given quicker which is of no concern. Medical council supports either method to deliver D10 and encourages paramedic judgment based on resources and equipment available, patient and scene characteristics and paramedic comfort with one method versus the other.